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Alfred M Cohen - One of the best experts on this subject based on the ideXlab platform.
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long term results of Local Excision for rectal cancer
Annals of Surgery, 2002Co-Authors: Philip B Paty, Garrett M Nash, Paul Baron, Maureen F Zakowski, Bruce D Minsky, David Blumberg, Daniel R Nathanson, Jose G Guillem, Warren E Enker, Alfred M CohenAbstract:Although Local Excision for rectal cancer has been practiced for more than 120 years, its proper use for cure of small, Localized rectal cancers is still incompletely understood. The appeal of Local Excision as definitive treatment is considerable. When accomplished by transanal Excision, the operation has very low morbidity. There is no need for permanent or even temporary colostomy. Recovery is rapid, and long-term bowel function is excellent. In contrast, radical surgery, even in expert hands, carries a significant risk of perioperative morbidity, may require a stoma, usually necessitates several weeks of recovery, and frequently leaves patients with compromised bowel or sexual function. 1–6 A prerequisite for using Local Excision as curative therapy in fit patients is the development and validation of selection criteria that can identify those patients who can be treated by Local Excision alone without compromising cancer cure. Such criteria remain incompletely defined. Tumor size and configuration, imaging properties by endorectal ultrasound (depth of tumor penetration, regional lymph node detection), and pathologic factors (T stage, grade, and vessel invasion) have all been useful in defining patient populations at low versus high risk of tumor recurrence after Local Excision. 7,8 Despite such selection criteria, Local Excision carries the unavoidable risk of unresected regional disease and incomplete pathologic staging because regional lymph nodes are not removed and are therefore not pathologically assessed. At present, preoperative imaging modalities cannot accurately predict the presence or absence of regional lymph node metastases. Moreover, there is currently no combination of postoperative clinical and pathologic factors that can completely exclude the risk of occult regional lymph node metastasis. 9,10 The limitation of Local Excision as a curative operation has been highlighted by recent reports that show a 10% to 40% risk of Local recurrence following Local Excision for T1 and T2 rectal cancers at median follow-up of approximately 5 years. 11,12 Strategies to enhance Local control of rectal cancer have included adjuvant chemoradiation therapy as well as close postoperative surveillance with surgical resection of Local recurrence. There have been no randomized studies of radiotherapy or chemotherapy to evaluate their efficacy in enhancing Local control following Local Excision. However, the enhanced Local control and survival rates achieved by adjuvant chemotherapy and radiation after radical rectal surgery 13,14 provide a strong rationale for their use in combination with Local Excision. Single-arm studies have shown that postoperative chemoradiation is well tolerated after Local Excision. However, the benefit in preventing cancer recurrence in this setting is unproven, with mature studies showing Local failure rates for T2 cancers after Excision and chemoradiation as high as 28%. 12,15–17 Another uncertainty is how often Local tumor recurrence can be cured by salvage radical surgery. This is an important question, as at least half of all recurrences are Local-regional. Currently, data on surgical salvage are limited, 11,12 and additional reports with long-term follow-up are needed. At Memorial Sloan-Kettering Cancer Center, Local Excision for cure of small rectal cancers has been used selectively for more than 30 years. 18,19 Since 1986 adjuvant radiotherapy and, more recently, adjuvant chemoradiotherapy have been used for selected cases judged to be at high risk for recurrence. 20 We have reviewed our institutional experience to evaluate the long-term cancer treatment results for Local Excision for primary rectal cancer and salvage surgery for recurrence.
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Conservative management of rectal cancer with Local Excision and postoperative adjuvant therapy
International Journal of Radiation Oncology Biology Physics, 1999Co-Authors: Raquel Wagman, Philip B Paty, Bruce D Minsky, Alfred M Cohen, Leonard Saltz, Jose G GuillemAbstract:Abstract Background: To determine the Local control, survival, and functional outcome of Local Excision plus postoperative therapy for patients with rectal cancer. Methods: A total of 39 patients underwent a Local Excision (2 with snare Excision of a T1 polyp and 37 with full-thickness Local Excision) followed by postoperative radiation therapy ± 5-FU-based chemotherapy. The median follow-up was 41 months, and 11 patients had positive margins. Results: The 5-year actuarial colostomy-free survival was 87% and overall survival was 70%. Crude Local failure increased with T stage: 0% T1, 24% T2, and 25% T3. Of the 8 patients (21%) who developed Local failure, 5 underwent salvage APR and were Locally controlled. Actuarial Local failure at 5 years was 31% for T2 disease and 27% for the total patient group. In the 32 patients with an intact sphincter, 94% had good to excellent sphincter function. Conclusion: Although Local failure in patients with T2 tumors has increased since our prior report, the survival, sphincter function, and Local salvage rates are acceptable. Local Excision and postoperative therapy remains a reasonable alternative to APR in selected patients.
Bruce D Minsky - One of the best experts on this subject based on the ideXlab platform.
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long term results of Local Excision for rectal cancer
Annals of Surgery, 2002Co-Authors: Philip B Paty, Garrett M Nash, Paul Baron, Maureen F Zakowski, Bruce D Minsky, David Blumberg, Daniel R Nathanson, Jose G Guillem, Warren E Enker, Alfred M CohenAbstract:Although Local Excision for rectal cancer has been practiced for more than 120 years, its proper use for cure of small, Localized rectal cancers is still incompletely understood. The appeal of Local Excision as definitive treatment is considerable. When accomplished by transanal Excision, the operation has very low morbidity. There is no need for permanent or even temporary colostomy. Recovery is rapid, and long-term bowel function is excellent. In contrast, radical surgery, even in expert hands, carries a significant risk of perioperative morbidity, may require a stoma, usually necessitates several weeks of recovery, and frequently leaves patients with compromised bowel or sexual function. 1–6 A prerequisite for using Local Excision as curative therapy in fit patients is the development and validation of selection criteria that can identify those patients who can be treated by Local Excision alone without compromising cancer cure. Such criteria remain incompletely defined. Tumor size and configuration, imaging properties by endorectal ultrasound (depth of tumor penetration, regional lymph node detection), and pathologic factors (T stage, grade, and vessel invasion) have all been useful in defining patient populations at low versus high risk of tumor recurrence after Local Excision. 7,8 Despite such selection criteria, Local Excision carries the unavoidable risk of unresected regional disease and incomplete pathologic staging because regional lymph nodes are not removed and are therefore not pathologically assessed. At present, preoperative imaging modalities cannot accurately predict the presence or absence of regional lymph node metastases. Moreover, there is currently no combination of postoperative clinical and pathologic factors that can completely exclude the risk of occult regional lymph node metastasis. 9,10 The limitation of Local Excision as a curative operation has been highlighted by recent reports that show a 10% to 40% risk of Local recurrence following Local Excision for T1 and T2 rectal cancers at median follow-up of approximately 5 years. 11,12 Strategies to enhance Local control of rectal cancer have included adjuvant chemoradiation therapy as well as close postoperative surveillance with surgical resection of Local recurrence. There have been no randomized studies of radiotherapy or chemotherapy to evaluate their efficacy in enhancing Local control following Local Excision. However, the enhanced Local control and survival rates achieved by adjuvant chemotherapy and radiation after radical rectal surgery 13,14 provide a strong rationale for their use in combination with Local Excision. Single-arm studies have shown that postoperative chemoradiation is well tolerated after Local Excision. However, the benefit in preventing cancer recurrence in this setting is unproven, with mature studies showing Local failure rates for T2 cancers after Excision and chemoradiation as high as 28%. 12,15–17 Another uncertainty is how often Local tumor recurrence can be cured by salvage radical surgery. This is an important question, as at least half of all recurrences are Local-regional. Currently, data on surgical salvage are limited, 11,12 and additional reports with long-term follow-up are needed. At Memorial Sloan-Kettering Cancer Center, Local Excision for cure of small rectal cancers has been used selectively for more than 30 years. 18,19 Since 1986 adjuvant radiotherapy and, more recently, adjuvant chemoradiotherapy have been used for selected cases judged to be at high risk for recurrence. 20 We have reviewed our institutional experience to evaluate the long-term cancer treatment results for Local Excision for primary rectal cancer and salvage surgery for recurrence.
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Conservative management of rectal cancer with Local Excision and postoperative adjuvant therapy
International Journal of Radiation Oncology Biology Physics, 1999Co-Authors: Raquel Wagman, Philip B Paty, Bruce D Minsky, Alfred M Cohen, Leonard Saltz, Jose G GuillemAbstract:Abstract Background: To determine the Local control, survival, and functional outcome of Local Excision plus postoperative therapy for patients with rectal cancer. Methods: A total of 39 patients underwent a Local Excision (2 with snare Excision of a T1 polyp and 37 with full-thickness Local Excision) followed by postoperative radiation therapy ± 5-FU-based chemotherapy. The median follow-up was 41 months, and 11 patients had positive margins. Results: The 5-year actuarial colostomy-free survival was 87% and overall survival was 70%. Crude Local failure increased with T stage: 0% T1, 24% T2, and 25% T3. Of the 8 patients (21%) who developed Local failure, 5 underwent salvage APR and were Locally controlled. Actuarial Local failure at 5 years was 31% for T2 disease and 27% for the total patient group. In the 32 patients with an intact sphincter, 94% had good to excellent sphincter function. Conclusion: Although Local failure in patients with T2 tumors has increased since our prior report, the survival, sphincter function, and Local salvage rates are acceptable. Local Excision and postoperative therapy remains a reasonable alternative to APR in selected patients.
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Conservative treatment of rectal cancer with Local Excision and postoperative radiation therapy
European Journal of Cancer, 1995Co-Authors: Bruce D MinskyAbstract:Abstract The conventional surgical treatment for patients with potentially curable transmural and/or node positive rectal cancer is a low anterior resection or abdominoperineal resection. Recently, there has been increasing interest in the use of Local Excision and postoperative radiation therapy as primary therapy for selected rectal cancers. The limited data suggest that the approach of Local Excision and postoperative radiation therapy should be limited to patients with either T1 tumours with adverse pathological factors or T2 tumours. Transmural tumours, which have a 24% Local failure rate, are treated more effectively with standard surgery and pre- or postoperative therapy. The results of Local Excision and postoperative radiation therapy are encouraging, but more experience is needed to determine if this approach ultimately has similar Local control and survival rates as standard surgery.
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Clinical experience with Local Excision and postoperative radiation therapy for rectal cancer
Diseases of The Colon & Rectum, 1993Co-Authors: Bruce D MinskyAbstract:The standard surgical treatment for patients with potentially curable transmural and/or node-positive rectal cancer is a low anterior resection or abdominoperineal resection. There is increasing interest in the use of Local Excision and postoperative radiation therapy as primary therapy for selected rectal cancers. The limited data suggest that the approach of Local Excision and postoperative radiation therapy should be limited to patients with either T1 tumors with adverse pathologic factors or T2 tumors. Transmural tumors have a 24 percent Local failure rate and are treated more effectively with standard surgery and preoperative or postoperative therapy. The results of Local Excision and postoperative radiation therapy are encouraging; however, more experience is needed to determine whether this approach ultimately has Local control and survival rates similar to standard surgery.
John R. T. Monson - One of the best experts on this subject based on the ideXlab platform.
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Oncologic Outcomes for Local Excision of Rectal Neoplasia
Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal Excision (taTME), 2020Co-Authors: Nathalie Wong-chong, John R. T. MonsonAbstract:Local Excision is a safe alternative to radical resection for benign lesions and early rectal cancer. Technological advances in Local Excision, such as transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS), have led to improved pathologic specimens with higher negative margin rates and less specimen fragmentation leading to improved oncologic outcomes. In select patients with T1 rectal cancers without adverse features, Local Excision with curative intent is associated with similar oncologic outcomes compared to TME surgery. Patients with more advanced tumors that refuse TME surgery or are medically unfit can be considered for neoadjuvant chemoradiation followed by Local Excision with low incidence of Local recurrence and comparable disease-free survival as TME.
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Is Local Excision of T2/T3 rectal cancers adequate?
Recent results in cancer research, 2020Co-Authors: Daniel L Beral, John R. T. MonsonAbstract:In selected patients, Local Excision of rectal cancer may be an alternative to radical surgery such as abdominoperineal Excision of the rectum or anterior resection. Local Excision carries lower mortality and morbidity, without the functional disturbance or alteration in body image that can be associated with radical surgery. There are several techniques of Local therapy for rectal cancer, with most experience being available in transanal Excision. Transanal endoscopic microsurgery is also used but experience with this newer technique is limited. Patient selection is the most important factor in successful Local Excision; however, specific criteria for selecting patients have not been universally accepted. Review of the published literature is difficult because of the variation in adjuvant therapy regimes and follow-up strategies, as well as results reported in terms of Local recurrence and survival rates. There is increasing evidence to suggest that Local Excision should be restricted to patients with T1-stage rectal cancer without high-risk factors. The place for Local Excision in patients with T2 or high-risk T1 tumours requires prospective, randomised multicentre trials comparing radical surgery with Local Excision, with or without adjuvant therapy. Local Excision for T3 tumours should be restricted to the palliative setting or patients unfit for radical surgery.
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Local Excision of rectal cancer review of literature
Digestive Surgery, 2005Co-Authors: Piero Nastro, John E. Hartley, Daniel L Beral, John R. T. MonsonAbstract:In selected patients, Local Excision of rectal cancer may be an alternative to radical surgery such as abdominoperineal Excision of the rectum or anterior resection. Local Excision carries lower morta
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Local Excision of rectal tumours
Surgical Oncology-oxford, 2003Co-Authors: A. Sharma, John E. Hartley, John R. T. MonsonAbstract:Abstract Local Excision is increasingly being used to treat rectal cancer. It appears to be an attractive option because of low morbidity and excellent functional results. Controversies remain regarding available techniques, selection criteria and results with or without adjuvant therapy. Role of salvage therapy remains uncertain. This review examines available evidence in an attempt to clarify the role of Local Excision in the management of rectal cancer.
Barry W Feig - One of the best experts on this subject based on the ideXlab platform.
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long term results using Local Excision after preoperative chemoradiation among selected t3 rectal cancer patients
International Journal of Radiation Oncology Biology Physics, 2001Co-Authors: M Bonnen, John M. Skibber, Nora A. Janjan, Christopher H Crane, Jean Nicolas Vauthey, Marc E Delclos, Miguel A Rodriguezbigas, Paulo M Hoff, Adrian Wong, Barry W FeigAbstract:Abstract purpose To assess the pelvic failure among patients with T3 rectal cancer treated with Local Excision after preoperative chemoradiation. Methods and materials Between January 1990 and June 2002, 431 patients with clinically staged T3 rectal cancer were treated with preoperative chemoradiation followed by surgical resection. Full-thickness Local Excision [Kraske ( n = 3) or a transanal Excision ( n = 23)] was performed in 26 patients because of patient refusal of abdominoperineal resection (APR) ( n = 13), medical comorbidity ( n = 4), physician preference after a complete clinical response ( n = 6), and other reasons ( n = 3). All patients were treated with continuous-infusion 5-fluorouracil (5-FU) (300 mg/m 2 Monday to Friday) and concomitant pelvic radiation (45 Gy in 25 fractions with a 3-field belly board technique). Ten Local-Excision patients received a concomitant boost during the last week of therapy (1.5-Gy second daily fractions) for a total dose of 52.5 Gy. Similar preoperative treatment was followed by total mesorectal Excision in 405 patients. Among the Local-Excision patients, the median tumor size was 3.5 cm (range, 0.5–7 cm). Well-differentiated or moderately-differentiated histology was present in all but 3 cases, and endoscopic ultrasound staging examination was performed in 25 of 26 patients. Based on CT findings, 1 patient was node positive. The median circumference involved by tumor was 33%, (20%–75%). The median distance from the anal verge was 3 cm (range, 1–8 cm). Results The mean follow-up was 46 months (range, 5–109 months) in the Local-Excision group. In the Local-Excision group, 19 of 26 patients had only residual scarring noted on digital rectal examination and rigid proctoscopy before surgery. Fourteen patients (54%) had a complete histologic response to chemoradiation, 9 patients (35%) had microscopic residual disease, and 3 patients (12%) had gross residual disease. Two intrapelvic recurrences occurred at 76 and 20 months among the 26 patients treated with Local Excision (6% 5-year actuarial pelvic recurrence rate). This rate compared with an 8% 5-year actuarial pelvic recurrence rate among T3 patients treated with mesorectal Excision and a 6% pelvic recurrence rate in the subgroup of mesorectal-Excision patients with a complete clinical response to preoperative chemoradiation. One additional Local-Excision patient recurred in an inguinal lymph node after Local Excision and subsequently died of metastatic disease. A total of 2 Local-Excision patients died of metastatic rectal cancer. Actuarial overall survival at 5 years was 86% in the Local-Excision group compared with 81% among mesorectal-Excision patients ( p = NS), and 85% in patients with a complete clinical response to chemoradiation followed by mesorectal Excision by APR or LAR ( p = NS). Conclusions In an experience stimulated by patient refusal of APR, highly selected patients who responded well to conventional external-beam radiotherapy (CXRT) were selected to undergo Local Excision. Most of these patients had pathologic complete response. Local control and survival rates are comparable to those achieved with chemoradiation followed by mesorectal Excision. This strategy should be prospectively studied in a group of patients with low rectal cancer who have no clinical evidence of tumor after chemoradiation.
Milburn J Jessup - One of the best experts on this subject based on the ideXlab platform.
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prospective evaluation of Local Excision for small rectal cancers
Diseases of The Colon & Rectum, 1997Co-Authors: Ronald Bleday, Milburn J Jessup, Elizabeth Breen, Anne Burgess, Stephen M Sentovich, Glenn SteeleAbstract:OBJECTIVE: Most data on Local Excisions for rectal cancer are based on retrospective studies. We review the results of a prospective registry of patients eligible for Local Excision of rectal cancer using a transanal, transsphincteric, or transcoccygeal technique combined with multimodality therapy for lesions penetrating the muscularis propria (T2) or perirectal fat (T3). METHODS: Patients with lesions less than 4 cm in diameter and less than 10 cm from the dentate line, with no evidence of distant metastases or invasion into the perirectal fat, were eligible for Local Excision. Patients with invasion into the muscularis propria (T2) or greater (T3) received adjuvant chemoradiation therapy. RESULTS: Forty-eight patients have been followed prospectively. Average age is 63 years. Thirty-three patients underwent a transanal Excision. Fifteen patients underwent either a transsphincteric or technique Excision. There was no perioperative mortality. Pathology revealed 1 Tis, 21 T1, 21 T2, and 5 T3 cancers. Mean follow-up is 40.5 months. Cancerrelated overall mortality was 4 percent. Overall Local or distant recurrence rate was 8 percent(4/48). Recurrence appeared to be related to presence of a positive margin or aggressive histology (lymphatic invasion). Local recurrences were treated with salvage therapy. CONCLUSION: Local Excision can be used selectively for small rectal cancers, with minimum morbidity. Recurrence rates are low (8 percent). Patients with either a positive margin or lymphatic invasion need to be considered for further therapy, including abdominoperineal resection, even with T1 lesions. Adjuvant chemoradiation appears to be a benefit for all T2 or T3 cancers.
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Local Excision of rectal carcinoma
American Journal of Surgery, 1990Co-Authors: Roger A. Graham, Lisa Garnsey, Milburn J JessupAbstract:Sixteen published series were reviewed in which Local Excision was used as definitive treatment for patients with invasive rectal carcinoma located within 6 cm of the anal verge. Ninety-four percent of tumors were T1 or T2 adenocarcinomas with no identified regional metastases. Five-year cancer-specific survival was 89%. Local recurrence was 19%, although more than half of these patients were cured with additional surgery. These results were comparable with those for historical controls treated with abdominoperineal resection (APR). Four pathologic features of the surgical specimen were analyzed to assess their correlation with patient outcome. Positive surgical margins, poorly differentiated histology, and increasing depth of bowel wall invasion were associated with increased Local recurrence and decreased survival. Tumor size greater than 3 cm was not a significant factor. When criteria for appropriate patient selection are followed, Local Excision may provide survival and recurrence rates comparable with those achieved with APR with less morbidity and operative mortality.